Provider Demographics
NPI:1861619991
Name:ROSE, AUDRA
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 PARK AVE
Mailing Address - Street 2:#1
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-3707
Mailing Address - Country:US
Mailing Address - Phone:201-386-1809
Mailing Address - Fax:201-386-1809
Practice Address - Street 1:65 BERGEN ST
Practice Address - Street 2:#601
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3001
Practice Address - Country:US
Practice Address - Phone:973-972-0186
Practice Address - Fax:973-972-2645
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00064000225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics